Always, always, always take a sexual history

When I was practicing interviewing patients in the hospital last week, I learned a very valuable lesson: always, always, always take a sexual history.

Every week, a classmate and I pair up with a patient, and one of us will take the history and the other will do the physical. It was my turn to interview the patient last week, a middle-aged man who was in the hospital for what appeared to be some kind of lung infection. As always, we were observed by our professor, and we met with her after the session to discuss how we can improve our bedside technique and the patient’s differential diagnosis.

I’m still really new (read: bad) at histories and physicals. There are somany things to remember, it seems, that I invariably leave out a question or two when I’m trying to get the patient’s history, or forget to do a maneuver during the physical. But last week, I really messed up: I completely forgot to ask the patient about his sexual history. My professor (the patient’s realdoctor) informed me that this man was gay and sexually active. In medicalese, we say this patient is in the category of MSM – men who have sex with men. For a patient who is MSM who presents with an infection of any kind, HIV should immediately be included in the differential diagnosis. According to the Center for Disease Control’s latest statistics, 53% of new cases of HIV are MSM, and the group has shared a disproportionate burden of the disease since its inception.

It’s not that I didn’t know how to ask about sexual history. They teach us to first normalize the situation by saying, “I need to ask you some personal questions now. We ask these questions to all of our patients.” That way, the patient does not think you are targeting them because of their race/ethnicity, gender presentation, or the way they dress. There is also a very specific way we are taught to ask about sexual preference: “Do you have sex with men, women, or both?” We do this because it is common for a person to identify as heterosexual, even if their sexual behavior is contradictory to that. As doctors, our only concern is the patient’s behavior, since it can put them at greater risk for certain diseases.

I really don’t know why I forgot to ask my patient about his sexual history. Maybe it’s because it is always uncomfortable to ask a complete stranger such personal questions, and subconsciously, I didn’t want to do it. Maybe I simply forgot, since there are so many things to ask the patient. Either way, I’m glad I made this mistake now, when it doesn’t count – I’m not really on the patient’s health care team, I’m just practicing. If I were actually in charge of this patient, I would have completely neglected to think of HIV as a diagnosis. Next year, I will be responsible for patient’s lives, and now I know I will never forget to ask about sexual history.